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Looking Good: What Designs Work Best for Residents:
An Interview with Jain Malkin
Nursing Homes, October 1993
Your expensive interior renovation has been completed and it is a knockout. Subtle, pastel- complemented by restful soft lighting, and white-on-white residents' bathrooms - a design almost sure to captivate residents, families, and board members alike. Right?
Wrong. After over 20 years specializing in health care facility interior design, and in preparation for writing a book, Jain Malkin dedicated herself to researching virtually everything that had been written about designing for the elderly, especially for those with diminished cognitive capacities (i.e. the majority of nursing home residents). What she learned, she says, contradicted conventional wisdom about "good" interior design for this resident population. In an interview with Editor Richard L. Peck, Ms. Malkin discussed the problems posed by nursing home interior design and - given the state of today's nursing home budgets - reasonable ways to address them.
Peck: What are the major shortfalls you've seen in nursing home interior design?
Malkin: I'd start with lighting. Most of it is 2x4 lay-in fluorescent which means lots of glare. Often nursing homes will change from cool white lamps to warm white fluorescent lighting which, unfortunately has a lot of red in it. Research has shown that the red end of the light spectrum is highly arousing and may contribute to restlessness and agitation in residents.
Second, many nursing homes have poor way-finding orientation. All corridors look the same, and as a result residents may choose to stay in their rooms than risk getting lost.
Third, color is used indiscriminately, with no real understanding of what is appropriate for this population. Very often the color schemes are based on the personal tastes of the owner or a large donor. So you have pastels and other color palettes that residents have difficulty seeing.
Fourth, there is a premium placed in some facilities on highly waxed floors. The glare created is actually painful to cataract sufferers, and other residents tend to become less mobile because the floors look like ice and they're afraid of falling. Again, they choose to stay in their rooms.
Fifth, resident rooms tend to be too small for privacy or independent mobility. The minimum turning radius and critical dimensions for maneuvering a wheelchair were adopted with disabled war veterans in mind, not the elderly with little upper body strength, so wheelchair mobility becomes a genuine concern. Anything we can do to get people out of bed and moving is very beneficial for their physical and emotional well-being.
Sixth, there is little contact with nature, flowers, and sunlight, though these have all been found to be highly beneficial to the elderly.
Seventh, residents' difficulties with depth perception tend to be ignored, so that white bathroom fixtures, for example, tend to blend in with white walls, leading to various mishaps.
Finally, acoustics are another problem area, with many facilities having large dining areas, for example, with high ceilings. There is a great deal of background noise in these areas, which makes it difficult for the hard-of-hearing to conduct any sort of conversation.
Peck: Elsewhere you have said that simply "sprucing up" the place - redoing the upholstery or the wall covering, etc. - is not enough in addressing interior design problems. Would you elaborate?
Malkin: Cosmetic changes tend to gloss over the problems I've discussed. The basic issue to be addressed by any design is enabling the resident to function at his or her optimal level. Even marginal gains in these are significant for many of these individuals. That is why it is important that residents should be able to see the colors clearly, to find their way without getting lost, to see the handrail contrasted against the wall, to be able to see where the wall starts and the floor ends (at the baseboard), and to be able to find and differentiate the furniture and fixtures that they use everyday. Problems of depth perception must be carefully addressed. Redecorating, particularly according to one's personal taste, normally doesn't address these issues.
Peck: In an "ideal world" of generous budgets for interior renovation, what would you like to see nursing homes do?
Malkin: In an ideal situation, they might start by creating L-shaped semi-private rooms, with excellent window views and considerable privacy for each resident. Corridors would have non-glare flooring such as a matte-finish linoleum that never needs waxing or perhaps carpeting - with the appropriate type of carpeting. Corridors would vary in width and deviate from the 8-foot-minimum standard and would have variable ceiling heights with light wells and clerestory windows.
Nursing units would have interior gardens with natural light; numerous small rooms for sitting and visiting instead of large multifunction day rooms; interior wandering paths with no dead-ends; and corridors with fluid, organic shapes instead of the constant 90-degree angles so characteristic of our institutions.
Housekeeping staff would refrain from using the foul-smelling disinfectants and cleaning agents and would pay more attention to the overall sensory experience of the residents. There has been research, most notably by Barbara Cooper, showing that elderly people with a diminished sense, such as sight or hearing, overcompensate in another sensory mode. One study indicated that incontinence may be a way of achieving more touching as overcompensation for another sensory deficit, such as losing one's hearing or vision. Although certainly one's sense of smell becomes impaired as one ages, one must not overlook this as an avenue to reach out to residents. I know of several nursing homes that bake frozen bread on the unit every day just to create that wonderful aroma in order to stimulate the appetites of Alzheimer's patients. Sense of touch is important, as well. Textured art that residents can touch and feel may compensate for other sensory deficit and, additionally, may provide a wayfinding landmark if placed in the right location.
Peck: What about the "real world" of nursing home interior design, where budgets are tight, at best?
Malkin: There are some incremental things that one can do that don't cost much but can make an important difference. One is to attempt to
differentiate various corridors in nursing units by applied architectural items, such as wood moldings or trims, columns at corner intersections, and strategically placed strong colors - bright reds, oranges, and yellows that are preferable for elderly residents with failing vision. Maybe the corridors can each be given a name; there is a nursing home that has given its corridors "street signs" with the names of famous movie stars to whom the elderly can relate, such as Carole Lombard. Redundant cueing would indicate that a photo of Carole Lombard should be placed alongside the name.
Stairwells can be marked in various ways, too. The door to the stairwell might have a wood cutout of flowers, for example, with the name of the stair so that the resident can be told, "As soon as you see the daisies, you know you are home." The first and last steps can be marked with 2-inch-wide fluorescent orange strips across the tread to prepare elderly walkers for coming to the top or bottom of the flight of stairs.
A major but relatively inexpensive change would be to relamp your fluorescent fixtures with full-spectrum lighting, which provides the full balance of color energies across the balance of color energies across the spectrum, as does sunlight. A good product of this type is VitaLite by DuroTest. the research has been striking in showing what this type of lighting can accomplish for nursing home residents: improvement in synthesis of vitamin D, enhancement of immunologic competency, reduced dental caries, and even improvement in cardiovascular health. It is important to realize, as well, that the elderly in nursing homes typically need 3.5 times the brightness of lighting that younger people do to be able to see contrasts.
Other important small steps to take might include planter boxes to introduce nature, adding a picture frame to the side of a resident's door for placement of photographs, and perhaps varying bedspreads, draperies, etc. to personalize the rooms. Acoustically, wall panels are available - Armstrong is one vendor - that can be used to absorb sound in noisy areas such as large dining rooms.
Peck: You alluded to the problem the elderly have in being able to see the contrast of objects they use daily. Would you elaborate on that?
Malkin: There are a number of simple steps that can be taken to help people with low vision in being able to distinguish important features of their environment and thereby function at their maximum abilities. One is called "color cueing." This should be distinguished from "color coding" - for example, painting all bathroom doors red. Research has shown that color coding doesn't work very well with the elderly in nursing homes, because they often have a difficult time making the cognitive connection. Color cueing (color contrast applied to key objects in the environment) on the other hand, combined with enhanced lighting, can aid people in dealing with and manipulating various objects.
For example, silhouettes can be painted on the wall behind the toilet and the toilet paper holder to make them contrast with the white bathroom walls. One can apply bright red, orange, or yellow tape around the edges of tables, bedside cabinets and drawer pulls to enable residents to locate them properly when they want to put something down. Because the aging eye often has difficulty in seeing colors of similar value (lightness or darkness), brightly-colored tape can also be applied to wheelchair wheel rims or brake handles. Brightly-colored fabric can be applied to the backs of wheelchairs, and upholstery fabrics in general should contrast with the color of the floor to make the chair stand out from its background.
There is another consideration in meeting residents' visual needs. It's called restricted upgaze. The normal eye level of many elderly residents is lower than one may realize, as many are unable to raise their heads, especially in later stages of Alzheimer's disease. As a result, much of the signage, artwork and other items that one would expect to be helpful to them simply can't be seen. Important signs, photographs and visual cues should be placed at the true eye level of these residents.
Peck: Any other tips along these lines?
Malkin: Choice of furniture is obviously very important. Unfortunately, I have often seen chairs and sofas in nursing homes that are totally inappropriate for elderly people. They are unstable, too deep from front to back, and too low for residents to get in and out of comfortably. Chairs and sofas should be well-balanced, have arms at the right height, and have a seat no lower - or higher - than 18 or 19 inches from the floor. They should be designed to handle the realities of nursing home life, i.e. there should be a space between the back and the seat and an absence of cording or welting on the edges so that urine won't collect and the chairs will be relatively easy to clean.
Peck: How might administrators and operators go about selecting an interior design consultant and working with him or her appropriately?
Malkin: In screening prospective consultants, I would ask them to discuss design issues that they see as specific to the nursing home environment. See if they are aware of such issues such as sensory deficits, problems with depth perception, cognitive impairment, lighting requirements, restricted upgaze, wandering behavior, and the differences between a custodial-oriented and a rehabilitation-oriented philosophy of care. These are the concerns one must deal with in this setting, not what aesthetic design features happen to be pleasing to management or donors. It's always a problem to decide whether one is designing to optimize residents' functioning or to appeal to the adult children to whom the nursing home is marketing.
And that ties in with what it takes to work appropriately with these consultants. Their best work is often diluted by having to work with board members, donors and other who are eager to express their personal tastes. The design committee should be small, perhaps no more that five or six people from management, with direct input from nursing supervisors who, of course, have the most direct contact with residents. Don't let housekeeping and maintenance issues overshadow equally important issues of creating a residential character and preserving residents' dignity; too many vinyl or plastic-coated fabrics, too much shiny floor tile, and too many stainless steel wall protectors speak too loudly of institutions. The designer should be willing to spend a night and several days at the facility, observing everything and taking notes. There is no substitute for this on-site experience in making correct design decisions. The designer should also be willing and able to show examples - photos, slide, etc. - of good design for the elderly, to educate the staff and management about new ideas.
I would add that it is also very important to educate residents' families, as well. If you follow some of the suggestions I've offered here, you may end up with a facility that looks somewhat strange to people who are healthy and functioning normally. You must reassure them that the facility looks this way because it is doing its job: keeping the residents as high-functioning and independent as possible.
October, 1993: Interior Expressions, Volume 42, Number 8